Dietitians add expertise to agency services
Dietitians add expertise to agency services
Nutritional assessment, education cut LOS
With accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations requiring providers to make nutritional assessments of their clients, some agencies are seeking the guidance of registered dietitians. The results have been overwhelmingly positive. Clients appreciate receiving nutritional expertise as an added service, and managed care organizations are happy because nutritional education can cut hospital stays and prevent readmissions.Health Spectrum, a hospital-based home care company that serves eastern Pennsylvania, has hired nutritionists and dietitians from its hospital, Lehigh Valley, on a per diem basis to do nutritional assessments on both its private duty and Medicare patients.
All of Health Spectrum’s pediatric private duty patients receive the assessment, says Deb Guattery, RN, program manager for Health Spectrum in Allentown, PA. These patients are on a total parenteral nutrition or enteral product or are on a ventilator.
"We have more than 28 ventilator-dependent children, and a lot of those children need constant nutritional assessment and updates," she explains. "That’s why we started looking at having someone on board to review our charts and get the red flags out — the patients who need to be followed more closely in their nutritional evaluation."
The nutritional service has been attractive to managed care organizations, which choose providers based largely on their overall value to consumers. "The fact that we’re able to provide another service has opened up a new dialogue with the managed care organizations in our area," Guattery says.
The dietitians’ knowledge also has made them an advantageous part of the care team, Guattery says. "They fill in a piece that a lot of nurses are not as knowledgeable about because their focus is different. They understand metabolism and mechanics and how it relates to the disease process.
"I find their resources invaluable," she adds. "There’s nothing that makes a parent happier than when their child maintains or puts on a little bit of weight when they are in a chronic disease state."
At her former company, Guattery had implemented a diabetic education program and had hired a certified diabetic educator to teach diabetic patients about their diets.
The need for nutritional guidance was especially great among patients recently diagnosed with juvenile diabetes, Guattery says. "Parents were leaving the hospital completely overwhelmed by the diagnosis [of insulin-dependent diabetes], especially in the inner-city areas of Philadelphia."
Many of the families did not have other family members with the diagnosis, and therefore, had no idea how to alter their diets. The dietitian was able to go into the clients’ homes, open up their cabinets, and point out what in their diet was fat, what was sugar, and how to measure actual serving sizes.
"She was able to use what was in the home so they could understand how to maintain the proper amount of caloric intake. That was most helpful to the parents who were trying to manage a newly diagnosed diabetic child, maybe the first one in the family," Guattery says.
The nutritional assessment also took the nurse out of the role of asking caloric intake questions, she adds. "It’s a tremendous amount of information, and the nurses are so busy focusing on checking blood sugar, drawing up and administering insulin properly, and checking for signs and symptoms of hyperglycemia and hypoglycemia."
In addition, the dietitian gave the parents another person they could turn to for support and information. "There wasn’t the anxiety with the family of I’m going to have to give my child a shot now.’ Their learning capabilities were so much more [with the dietitian] because they were no longer worried about having to give the insulin injection or test the blood sugar. They were more focused on I need to learn how to change our dietary routine to manage my child’s diabetes at home and make sure he stays within normal blood sugar limits.’"
Billing the service to HMOs
As a per diem employee, the dietitian submitted a charge per hour for the visits she made. Guattery says she negotiated with several HMOs to pay for the visits. "We built the cost of her services into the pricing for the HMO," she says. Until the contract was signed, the agency billed separately for the dietitian’s visits to make sure it was reimbursed for her nutritional teaching and assessment.The HMOs agreed to reimburse some or all of the visits when they realized they reduced the amount of in-hospital time for education, she explains. "When we first started this program, the local children’s hospital was keeping children with new onset of diabetes for five to 10 days just for teaching and glucose monitoring. Of course the HMOs say, No way.’ They cut it down to three days of in-hospital, and then they were making a referral to that agency to pick up the teaching."
The nurse went to the client’s home several times a day for the first couple of days, especially for the injections. The dietitian made a separate visit to get the family started on the dietary education. The agency also continued to monitor the client for a year’s worth of outcomes.
The dietary service was more cost-effective for some families than for others. For families with a resource base and strong support system, the dietitian might be in and out of the home in one visit.
Other families, however, needed weekly visits by the dietitian for at least a month to make sure they were able to follow the program. "The nurse is pretty much out of there by that time because the families learn to give the injections. But the dietitians maintain the contact, and we’re still being able to charge an appropriate fee to the HMOs to recoup some of that cost."
Guattery recommends working with a dietitian on a per diem basis or as an independent contractor to see if you can sell the service to payers in your area. "If they find that it is financially feasible, then bring someone in full-time," she says.
[Editor’s note: For a referral to a registered dietitian in your area, call the American Dietetic Association at (800) 366-1655.]
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